NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

However, based on the available data, 588 the panel recommends continuing trastuzumab therapy for up to 1 year. Determination of response to neoadjuvant chemotherapy in IBC should include a combination of physical examination and radiologic assessment. Surgery Patients with a clinical/pathologic diagnosis of IBC should always be treated with chemotherapy before surgery. It has been known for many years that surgical treatment as primary treatment of patients with IBC is associated with poor outcomes. 594 SLN dissection is not a reliable method of assessing ALNs among women with IBC. 595 Use of breast-conserving surgery in patients with IBC has been associated with poor cosmesis, and limited data suggest that rates of local recurrence may be higher when compared with mastectomy. Breast-conserving therapy is not recommended for patients with IBC. Mastectomy with level I/II ALN dissection is the recommended surgical procedure recommended by the NCCN Panel for patients who respond to neoadjuvant chemotherapy. The NCCN Panel has listed delayed breast reconstruction as an option that can be recommended to women with IBC who have undergone a modified radical mastectomy. Reconstruction of the breasts soon after mastectomy may compromise the post-mastectomy radiation therapy outcomes. 596 For patients with IBC who do not respond to preoperative systemic therapy, mastectomy is not generally recommended. Additional systemic chemotherapy and/or preoperative radiation should be considered for these patients, and patients responding to this secondary therapy should undergo mastectomy and subsequent treatment as described above.

addition, patients who had a pCR in the ALNs had superior overall- and DFS compared with those with residual axillary disease. 587 The NCCN Panel recommends preoperative systemic therapy with an anthracycline-based regimen with or without taxanes for the initial treatment of patients with IBC. The Panel also recommends completing the planned chemotherapy prior to mastectomy. If the chemotherapy was not completed preoperatively, it should be completed post-operatively. Targeted Therapy All women with hormone receptor-positive IBC are recommended to receive endocrine therapy sequentially after completing the planned preoperative systemic therapy. For women with HER2-positive disease, the addition of trastuzumab to primary systemic chemotherapy is associated with better response rates. 588-592 A prospective study that randomized women with locally advanced breast cancers, including those with IBC, to neoadjuvant anthracycline-based chemotherapy with or without trastuzumab for 1 year demonstrated that the addition of trastuzumab significantly improved the response rate and event-free survival. 588 Results of small phase II trials indicate that other HER2 targeting agents such as lapatinib and pertuzumab have IBC. 169,593 These results need further validation from larger prospective trials. The NCCN Panel recommends inclusion of trastuzumab in the chemotherapy regimen, and is recommended for patients with HER2-positive disease . There are no available data to indicate the optimal duration of trastuzumab, specifically among women with IBC.

Version 2.2015, 03/11/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. MS-64